Form Sfn 54147 - Application For Registration Of Securities By Announcement - Secondary - 2012

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Securities Department

APPLICATION FOR REGISTRATION OF

600 E Boulevard Ave - Dept 414

Bismarck, ND 58505

SECURITIES BY ANNOUNCEMENT - SECONDARY

(701) 328-2910

SECURITIES DEPARTMENT

SFN 54147 (8-2012)

Under Section 10-04-07.1 of the Securities Act of 1951 as amended.

Dealer Applicant

Address

City

State

Zip Code

Name of Issuer of Securities Being Registered

Principal Office Address

City

State

Zip Code

Title of Securities Being Registered

Current Market

Bid

Ask

Last Twelve Month High

Last Twelve Month Low

Bid

Ask

Bid

Ask

Earnings History per share for 5 years (except for newer companies)

Average for Period

Subject securities have been outstanding and in the hands of the public for not less than one year.

Yes

Include a financial statement or Offering Circular containing a financial statement not more than 12 months old. If not available, indicate date when ready.

Subject Securities Previously Registered

Date of Latest Registration

In North Dakota

With Securities & Exchange Commission

If the securities being registered are life insurance company stocks qualifying under the second paragraph of Section 10-04-

07.1 of the North Dakota Securities Act of 1951, as amended, please supply information as stated in Subsection 1 of Section

10-04-07.1.

Securities entitled to registration by announcement may be registered only by a dealer registered with the Securities

Department.

The filling fee is twenty-five dollars ($25.00).

The undersigned under oath says that he/she has executed the foregoing application for and on behalf of the applicant

named above; that he/she is ___________________________ of such applicant and is fully authorized to execute and file